Optimizing neuromuscular block monitoring and reversal: A large-scale quality improvement initiative in a diverse healthcare setting.

Abstract

Background: Residual neuromuscular block (NMB) after anesthesia poses significant risk to patients, which can be reduced by adhering to evidence-based practices for the dosing, monitoring, and reversal of NMB. Incorporation of best practices into routine clinical care remains uneven across providers and institutions, prompting the need for effective implementation strategies.

Methods: An interdisciplinary quality improvement initiative aimed to optimize NMB reversal practices across a large multi-campus urban medical center. Using the Institute for Healthcare Improvement (IHI) framework, interventions were designed to increase Train-of-Four (TOF) monitoring and promote evidence-based and cost-effective use of the NMB reversal agents. Process and outcome measures were tracked through Plan-Do-Study-Act (PDSA) cycles. Qualitative interviews provided insights into clinician perspectives.

Results: The study encompassed 35,198 surgical cases utilizing NMB agents. The interventions led to a sustained increase in TOF monitoring from 42 % to 83 %. Significant increases were also observed in TOF ratio documentation and utilization of sugammadex. Postoperative respiratory complication rates decreased by 41 % (RR 0.59, 95 % CI 0.32-0.96) over the course of the initiative. The most pronounced increases in TOF monitoring were associated with financial incentives for the achievement of department-wide target monitoring rate.

Conclusion: This initiative demonstrates successful large-scale integration of quantitative TOF monitoring and evidence based NMB management across a diverse medical center, while highlighting important barriers in implementation. These findings contribute to the broader discussion on translating evidence into practice, offering insights for improving patient care and safety through tailored implementation strategies.